If you have little kids who sometimes take pain or fever medications, you will want to check your medicine cabinet for this recall.

Three lots of Infants’ Ibuprofen Concentrated Oral Suspension have been recalled because the concentration in the bottle might be higher than they it is supposed to be.

What does that mean?

Although they are supposed to be at a 50mg per 1.25ml concentration, if it is indeed higher, then if you gave your child 1.25ml, they might get more than just 50mg.

“To date, Tris Pharma, Inc. has not received any reports of adverse events related to the lots of product that are the subject of this recall.”

How much more? We don’t know, since we don’t know what the “potentially” higher concentration might be.

Infants’ Ibuprofen Concentrated Oral Suspension Recall

Fortunately, the recall is limited to just 3 lots of Infants’ Ibuprofen Concentrated Oral Suspension that were made by Tris Pharma, Inc. and sold under the Equate, CVS Health, and Family Wellness brands and sold at Wal-Mart, CVS, and Family Dollar stores.

Do you have any recalled Ibuprofen? Check your lot numbers!

If you have the recalled Ibuprofen, don’t use it. Contact Tris Pharma for a refund.

And seek medical attention if you think your child got too much Ibuprofen and is having any symptoms, especially nausea, vomiting, epigastric pain, or more rarely, diarrhea.

Fortunately, getting extra Ibuprofen is not usually as dangerous as getting extra Acetaminophen.

Although, of course, neither is good! Be careful when dosing your kids and be sure they need it first.

Oh, and yes, at least in this case, store brand Ibuprofen at Family Dollar and Wal-Mart is the same as store brand Ibuprofen at CVS…

Like this:

Have you heard the news that the FDA has approved the first generic version of the EpiPen?

“The U.S. Food and Drug Administration today approved the first generic version of EpiPen and EpiPen Jr (epinephrine) auto-injector for the emergency treatment of allergic reactions, including those that are life-threatening (anaphylaxis), in adults and pediatric patients who weigh more than 33 pounds.”

FDA Press Announcement on FDA approves first generic version of EpiPen

That prompted Mylan, the company that makes the EpiPen 2-Pak and EpiPen Jr 2-Pak, to come out with a half-price authorized generic version last year.

“An authorized generic is made under the brand name’s existing new drug application using the same formulation, process and manufacturing facilities that are used by the brand name manufacturer.”

An authorized generic Adrenaclick injector also became available for a cash price of $109.99 CVS pharmacies. Combined with a $50 coupon, that’s often your best deal on an epinephrine injector if you don’t have insurance.

How Much Will the First Generic Version of EpiPen Cost?

And now we have a true generic version of the EpiPen 2-Pak and EpiPen Jr 2-Pak, from Teva Pharmaceuticals USA.

“The reduction in upfront research costs means that, although generic medicines have the same therapeutic effect as their branded counterparts, they are typically sold at substantially lower costs.”

FDA on Generic Drug Facts

Will it be cheaper than current EpiPens?

“When multiple generic companies market a single approved product, market competition typically results in prices about 85% less than the brand-name.”

FDA on Generic Drug Facts

It should be, but how much cheaper will it be?

“A company spokeswoman declined to say when it would be available, or how much it would cost.”

F.D.A. Approves Generic EpiPen That May Be Cheaper

While most folks would be happy with a $90 EpiPen and a tier 1 generic copay, I wouldn’t count on it. For one thing, we technically don’t have multiple generic EpiPens competing against the TEVA EpiPen yet.

And looking at drug prices of some of TEVA’s other medications, you can get a clue about their pricing plan:

Airduo generic (similar to Advair, but about 1/4 the price) – $98

Qvar (similar to Flovent) – $200

ProAir (albuterol inhaler) – $71

Budesonide Inhalation Suspension (generic Pulmicort Respules) – $176

Levalbuterol Inhalation Solution, USP (generic Xopenex) – $121

Clindamycin Phosphate and Tretinoin Gel (generic Ziana) – $600

Cefdinir oral suspension (generic Omnicef) – $45

Syprine (generic trientine hydrochloride) – $18,375

Their drugs typically ain’t cheap…

Will the first generic version of the EpiPen simply be a little cheaper than the authorized generic or can we expect TEVA to offer it at substantially lower cost?

We got less expensive alternatives after folks complained and there was a lot of media attention, but many other drugs are still expensive.

Did you know that there is a diaper rash cream on the market that costs over $600? What’s startling, is that the cream, Vusion, is simply made up of three ingredients that are available over the counter – miconazole (an antifungal drug), zinc oxide, and petroleum jelly.

There is also a pill for pinworms, Emverm, that costs $600!

Saving Money on Pediatric Prescriptions

There is one very easy way to save money on your next pediatric prescription.

That’s right, make sure your child really needs it.

No, that doesn’t mean not filling your pediatrician’s prescription, but it can mean simply asking if a prescription medication is really necessary the next time your kids get sick. Unfortunately, many conditions are over-treated, from ear and sinus infections to pink eye and reflux.

Also, when your child does need a prescription, instead of asking for a coupon, ask if a lower cost, generic alternative might be appropriate.

You can also:

make sure the medication is covered by your drug plan, if you have one

get a 90 day supply if it is a medication that your child uses long-term, like to control asthma

ask about optimizing your child’s dose so that they don’t need multiple pills, for example, taking one 30mg capsule is likely less expensive than taking two 15mg capsules each day

see if an alternative form of the same medication might be less expensive. For example, a tube of mupirocin (Bactroban) cream is a lot more expensive than a tube of mupirocin ointment, although both forms of the topical antibiotic can be used in the same situations. Similarly, ondansetron (Zofran) syrup is more expensive than ondansetron orally disintegrating tablets, which is often used when kids have nausea and vomiting.

To save money on prescriptions, you might also use a service like GoodRx, to search for the lowest prices at nearby pharmacies. Especially if you have a high deductible or if a medicine isn’t covered by your insurance, it can sometimes be cheaper to use GoodRx, or a similar service with discount cards, than to go through your insurance plan. And remember that some pharmacies, like at Walmart, offer many $4 generic drugs.

Lastly, ask your pediatrician for samples and go through the manufacturer’s patient assistance plan for help paying for your medicines.

Prescribe These Inexpensive Medications, Not Tho$e

Still can’t afford your child’s prescription?

Fortunately, there is almost always an alternative medication that is less expensive, but will work just as well, that you can ask your pediatrician about. It doesn’t do your child any good if your pediatrician prescribes a medication, but you don’t get it because you can’t afford it. Ask about an alternative instead.

In general, if you need a coupon to get the drug, you can expect that it is an expensive medication. And even if the coupon makes it affordable for you, remember that someone is still paying for it, and in the end, that’s likely going to be you in the form of higher insurance rates.

*To be clear though, these aren’t direct brand name to generic equivalents. Most are less expensive alternative medications that many pediatricians use every day though. Many were once the primary treatment and were found to work well. They were eventually replaced by newer medications, which were thought to work better, even though there are rarely head-to-head studies that actually prove that they work better than older, now less expensive medicines.

AirDuo – this is a generic preventative asthma inhaler, which like Advair, combines fluticasone propionate and salmeterol. The main downside? It can’t be used with a spacer.

Before looking for lower cost antibiotic eye drops to treat pink eye, you should maybe reconsider the need to treat pink eye in the first place. Most experts now think that pink eye is usually a viral infection, and even when it is caused by a bacteria, unless it is severe, it will likely go away without treatment. Most importantly, keep in mind that according to the AAP, “exclusion is no longer required” for kids with pink eye if they are in daycare or school, which is often why many parents seek treatment in the first place.

Epinephrine injectors are lifesaving medicines for kids with food allergies. They were one of the first medicines to expose how drug coupons helped drug prices soar (the $600 EpiPens), while parents got free medicines for their kids – at least if they had insurance and a co-pay to worry about. Those paying cash or who had a high deductible plan were stuck with high priced drugs. Less expensive epinephrine injectors are now available, but one of the most expensive medicines on our list is back – Auvi-Q. Although the manufacturer advertises that it is available for just $0 for commercially insured patients, each injector pack (comes with 2 injectors and a trainer) actually costs up to $2,500! And since it is recommended that kids have multiple injector packs to store in multiple places, the real price is at least $5,000.

Suprax (cefixime) was once a popular antibiotic for UTIs, especially once it became generic. Then, because it was maybe not popular enough, they stopped making it. It came back though, but not with a generic price tag. Some push it as a better choice for kids with persistent ear infections, but keep in mind that when mentioned on the list of antibiotics in the AAP ear infection treatment guide, it is suggested that when multiple antibiotics have failed, “a course of clindamycin may be used, with or without an antibiotic that covers nontypeable H influenzae and M catarrhalis, such as cefdinir, cefixime, or cefuroxime.” There is likely no benefit to using Suprax by itself or over a less expensive antibiotic.

Can you really use ofloxacin ophthalmic drops in a child’s ear? Yes, although it is an off-label treatment. You just can’t use otic (ear) drops in a child’s eyes. While eye drops are sterile, ear drops aren’t. And for some reason, eye drops are less expensive than ear drops.

Most newer, once a day ADHD medicines are expensive. Some aren’t even covered on insurance plans. Generic medicines are going to be less expensive than newer brand name medicines and short acting stimulants, like Adderall and Ritalin, are the cheapest. Your child just has to take a repeat dose around lunch time.

In many ways, we have come a long way in treating infants with reflux. Gone are the days of using medicines with dangerous side effects, like Propulsid (cisapride) and Reglan (Metoclopramide). Now, if they have gastroesophageal reflux disease (GERD), they are usually treated with an antisecretory agent to reduce acid and pain, but not necessary reduce the amount of spitting up. This can include histamine H2 receptor antagonists, like Zantac (ranitidine), and proton pump inhibitors (PPIs). Before Nexium packets for delayed release oral suspension became available, we had Prevacid Solutabs, which are now available OTC. This would be an off-label treatment.

Clarinex and Xyzal are new classes of medications that turn a drug made up of a racemic mixture (Claritin and Zyrtec) into a single enatiomer. Basically, these drugs are made up of two mirror images of themselves. The theory is that if you make a new drug with just one of those mirror images, then it will work better and cause less side effects. For the great majority of people, these new drugs just cost more. Xopenex was one of the first drugs to use this method, as it is just the R-enantiomer or isomer of albuterol = levalbuterol. Does it work better than albuterol? No. Some people do think that it has fewer side effects, so it might be worth a try if your child gets very jittery or gets an elevated heart rate when he takes albuterol.

Why try an over-the-counter medicine when prescription medications are available? Many medicines that are now over-the-counter, from Allegra and Claritin to Flonase and Nasacort, used to only be available with a prescription. Like these and many more medications, Zaditor allergy eye drops was once a prescription drug. It is available for kids who are at least three years old and might be worth a try before you spend money on a more expensive allergy eye drop.

In general, just remember that the “latest and greatest” medication isn’t always the greatest. Sometimes it is just newer and more expensive. Don’t be afraid to ask about an alternative if it is too expensive.

What to Know About Saving Money on Pediatric Prescriptions

Medications can be expensive, but there are things you can do to try and save money the next time your kids get a prescription from their pediatrician.

montelukast (Singulair) – a leukotriene receptor antagonist that can help prevent asthma and allergy symptoms

Two of these, inhaled steroids and inhaled long acting bronchodilators, which are typically used in combination products (Advair, AirDuo, Dulera, and Symbicort), are commonly used every day to prevent asthma symptoms and asthma attacks.

How Kids Take Asthma Medications

Asthma is one of those conditions that should be a lot easier to control than it usually is.

Although many preventative medications are available, they typically have to be used every day and the medications have to be given with a nebulizer (takes time) or an inhaler (requires good technique).

Fortunately, younger kids who can’t yet learn to use an inhaler can get around this by using their inhaler with a spacer or a spacer with a mask.

How do spacers work with your child’s asthma inhaler?

The medicine from the inhaler goes in the spacer and then the child can just breath it in, not having to coordinate, or time when they breath, with when the medicine actually comes out of the inhaler.

What’s the problem?

More and more drug companies are switching to dry powder inhalers. These are great for older kids, who can easily master the necessary technique – a quick, deep breath. But they are still too hard to use for younger kids and can’t be used with a spacer.

“In a systematic review, the mean percentages of patients who used their inhalers without mistakes were 63% for metered dose inhalers (MDIs); 75% for breath-actuated MDIs; and 65% for dry powder inhalers (DPIs).”

Haughney et al. on Choosing inhaler devices for people with asthma: Current knowledge and outstanding research needs

Others are switching to breath-actuated aerosol inhalers that are also too difficult for younger kids to use (they must close their lips around the mouth piece and inhale deeply) and also can’t be used with a spacer.

The Redesigned QVAR Inhaler

While some companies still make two versions of their inhalers, a traditional metered dose inhaler (MDI) and a dry powder inhaler (DPI) or breath-actuated device, more and more have just one option.

QVAR, which has long had the popular inhaled steroid QVAR HFA in 40 and 80 mcg strengths, has now switched to a breath-actuated device.

While the availability of the QVAR RediHaler is good news, as some experts think that breath-actuated devices are better than coordinated devices, the bad news is that they dropped their older QVAR inhalers which could be used with a spacer.

Be careful that your pharmacy doesn’t switch your child from QVAR to QVAR RediHaler unless you think it is appropriate.

Is your child’s asthma under poor control, so that QVAR wasn’t a good option anymore anyway, in which case your child might need a step up to a combination inhaler that can be used with a spacer, such as Advair, AirDuo, Dulera, or Symbicort?

Is your child’s asthma under such good control that your pediatrician might consider a step down off daily inhaled steroid therapy, so that you can stop using QVAR?

Do you have a nebulizer and so can use budesonide (Pulmicort) respules instead?

Although the fact that it has “a spacer-free design” is being used as a selling point for the new QVAR RediHaler, that doesn’t help those kids who still need to use a spacer. For them, the easiest option is to simply switch to another brand of steroid inhaler that can still be used with a spacer. These include Flovent HFA (44, 110, and 220mcg) and Alvesco (80 and 160mcg). Both are usually more expensive than QVAR though, which is what made QVAR popular. These other inhalers also might not be covered by your insurance plan.

The Future of Asthma Inhalers

Now that the patents on HFA inhalers are expiring, instead of making inexpensive HFA inhalers, to keep drug prices high, drug companies are developing new delivery devices that they can patent. What’s surprising, is that QVAR is made by Teva, which traditionally makes “lower cost” generic medications.

“Daddy, why can’t they put my asthma medicine in a spray-can like they do hair spray?”

Stein et al. on The History of Therapeutic Aerosols: A Chronological Review

In 1955, a young girl asked her father a simple question and a few months later, the first MDI for asthma was developed.

Can asking a simple question about asthma inhalers get us such quick results today?

Let’s see…

Why isn’t someone making inexpensive asthma inhalers?

Teva did recently get approval for their AirDuo brand and generic inhaler.

A combination of fluticasone propionate and salmeterol, AirDuo is similar to Advair. It is different in that the three strengths of AirDuo (55/14, 113/14 and 232/14 mcg) don’t exactly match the three strengths of Advair (45/21, 115/21 and 230/21 mcg), but at about 25% of the cost, few folks likely care. They might care that AirDuo is only available in a RespiClick version (a dry powder inhaler), and so can’t be used with a spacer.

Ironically, Teva’s AirDuo generic inhaler, a combination inhaler, is less much expensive than their QVAR inhaler, which only contains a steroid.

We will hopefully see more generic versions of more inhalers, including more that stay in a traditional non-breath-actuated, non-DPI form. And more asthma inhalers that are much less expensive.

What to Know About QVAR Being Redesigned

The redesign of QVAR and other asthma inhalers to breath actuated and dry powder versions can mean that they can’t be used with spacers and so can’t be used by infants, toddlers, preschoolers, and younger school aged children with asthma.